A 46-year old cattle rancher presented to an outside hospital with an acute onset of abdominal pain. He was diagnosed with hemorrhagic pancreatitis and sepsis and transferred to our facility for further care. On arrival, hemoglobin was 5.4 gm/dl, and WBC 13,200. He had a profound metabolic acidosis, severe coagulopathy, and was hypothermic.
The patient was aggressively resuscitated, and bleeding was controlled by embolization of the gastroduodenal artery. During the resuscitative process the patient experienced sudden oliguria and elevation of peak airway pressures. IAP was 32mm Hg. He was taken emergently to the OR for decompressive laparotomy. Given his hemodynamic instability, a modified Bogota/IV bag was placed.
48 hours later, the patient was returned to the OR and the Bogota/IV bag was replaced with a Wittmann Patch. Due to sepsis and on-going fluid requirements, the patient required an open abdomen for an extended period of time.
Over the next month, the fascial edges were gradually reapproximated in the ICU. On postoperative day 31 the patient was returned to the OR for patch removal and primary fascial closure. There were no wound complications and the patient was eventually discharged.
At one year follow-up the patient had returned to full activity on his cattle ranch and had no evidence of a hernia.
Overlapping hook and loop sheets helped prevent fascial retraction and allowed for reapproximations.
Case report courtesy of
Alison Wilson, MD, Assistant Professor Division of Trauma and Emergency Surgery
West Virginia University Health Sciences Center
Morgantown, WV 26506